For the provision of alcohol problems treatment in the UK, the most relevant finding from Project MATCH concerns the absence of clinically significant differences in
outcomes from the treatments studied.
Project MATCH found that a less intensive and less costly treatment (MET) resulted in similar outcomes to two more intensive and expensive treatments (CBT and TSF). This applied to all levels of severity of the clients’ alcohol problems and to all levels of alcohol dependence among those included in the project.
Owing to the large number of clients in each of the two samples, this absence of differential outcome is very unlikely to have been an error due to lack of statistical power. Therefore, it is possible to conclude that, among the normal range of clients attending for specialised treatment in the USA, MET was found to be equal in effectiveness to, and therefore more cost-effective than, CBT and TSF.
Although the Fellowship of Alcoholics Anonymous is a vital part of the response to alcohol-related harm in the UK, TSF is less relevant to specialised treatment provision in the UK than in the USA. However, cognitive behavioural treatment is widely used in Britain and would be regarded by many treatment providers as the most effective form of psychosocial treatment. Therefore, a possible deduction from Project MATCH findings is that motivational
enhancement therapy should become the main treatment of choice in services for problem drinkers on the grounds of cost-effectiveness.
Before this conclusion could be accepted, however, it was necessary to conduct a trial of treatment for alcohol problems in the UK to explore the implications of Project MATCH for British services. It is hazardous to extrapolate directly from the findings of Project MATCH to the UK treatment situation because:
• All clients taking part in Project MATCH were directed
towards total abstinence. In the UK, however, roughly 20 per cent of clients of a typical specialist alcohol agency are directed towards a moderation goal (Rosenberg et al., 1992)
• More generally, differences between the way
healthcare is funded and provided in the two countries make it essential to check important findings obtained in the USA in this country
• The cultural setting in which treatment takes place
may also be crucial in ways that are difficult to anticipate.
Partly to meet this need for a British trial following on from Project MATCH, in 1998 the Medical Research Council awarded a grant for a major, multi-centre trial of treatment for alcohol problems. The UK Alcohol Treatment Trial (UKATT) involved three clinical research centres (in Leeds, Birmingham and Cardiff), five treatment sites around these centres involving both statutory and non-statutory
services, a training centre (Leeds), a centre responsible for economic evaluation and statistical analysis (York) and a research co-ordinating centre (Newcastle). The
hypotheses, research design and methods of the trial were described by the UKATT Research Team (2001). Two treatments were compared:
• Social behaviour and network therapy (SBNT;
Copello et al., 2002). This was specially developed for the trial on the basis of strong support from theory and research regarding the most effective forms of treatment for alcohol problems. SBNT was scheduled for eight weekly 50-minute sessions
• Motivational enhancement therapy (MET). In the
UKATT, MET consists of three 50-minute sessions over eight weeks.
The effectiveness and cost-effectiveness of these two treatments were examined in a randomised design. Open follow-up (in which the treatment the client had received was known to the interviewer) was carried out at three months after entry to the trial and blind follow-up (where the client’s treatment group was unknown to the interviewer), forming the main analysis, at one year after entry. Various aspects of treatment outcome were
measured for the three months preceding the assessment point.
3.6.1
Hypotheses
UKATT hypotheses were formally expressed as null hypotheses on methodological grounds (see UKATT Research Team, 2001) but it will be more meaningful here to describe them as having a specific direction. There were two main hypotheses:
1 More intensive, socially based treatment (SBNT) will be more effective than less intensive, motivationally based treatment (MET)
2 Less intensive, motivationally based treatment (MET) will be more cost-effective than more intensive, socially based treatment (SBNT).
There were also five subsidiary hypotheses involving predictions of interactions between client characteristics and treatment outcomes (matching hypotheses). These were based partly, but not completely, on client-treatment matches that had been discovered in Project MATCH. At the time of writing, the data relevant to these subsidiary hypotheses is still being analysed and will not be commented upon further.
3.6.2
Design characteristics
Details of the trial design, procedures and assessments can be found in UKATT Research Team (2001). It is more relevant here to focus on some general principles and characteristics that determined the kind of trial carried out:
• A pragmatic trial. In a pragmatic trial, treatments are
compared under the conditions in which they would be applied in practice and the findings of the study are intended to be directly applicable to decision-making in clinical practice
• An effectiveness trial. Effectiveness trials are
conducted in “real world” conditions and seek to maximise external validity (generalisation to practical clinical situations)
• Training, supervision and quality control of
treatment delivery. In this aspect of the trial, the UKATT investigators built on the high standards set in Project MATCH (Tober et al., 2006)
• Treatment process. In addition to a comparison of
outcomes between two forms of treatment for alcohol problems, there was also a focus on examining treatment process (the “how” of treatment – see
chapter four) by both quantitative and qualitative methods (Orford et al., 2006)
• Economic evaluation. While most published studies
have used retrospective data to investigate the cost- effectiveness of treating alcohol problems, in UKATT, data from clinical sites and clients was gathered concurrently with all other data, the main aim being to compare the additional costs and benefits of SBNT compared with MET and to comment on the cost- benefits applying to UKATT treatments as a whole (see chapter 14).
3.6.3
Findings
Figures 3a and 3b show changes from baseline to one- year follow-up on the two main outcome measures of alcohol consumption used in the trial – percentage days of abstinence (PDA) and drinks per drinking day (DDD). The main outcomes from the trial are described in more detail by the UKATT Research Team (2005a).
On each of the outcome measures in figures 3a and 3b, both groups showed marked (and statistically significant) improvements at three-month follow-up and one-year follow-up. However, there were no significant differences between groups in changes on either of these measures. The same pattern of results was seen for alcohol
dependence (Leeds Dependence Questionnaire: Raistrick et al., 1994), alcohol-related problems (Alcohol Problems Questionnaire: Drummond, 1990) and psychiatric co- morbidity (General Health Questionnaire: Goldberg, 1972). To summarise, no statistically significant differences on changes in outcomes measures were observed and the first hypothesis (section 3.6.1) was therefore not confirmed.
To convey better the clinical significance of UKATT findings, figure 3c shows one-year outcomes according to a classification scheme developed by Heather and Tebbutt (1989). This focuses primarily on changes in alcohol-related problems from baseline to follow-up. As will be obvious from figure 3c, there were no significant differences between groups in proportions of clients allocated to these categories.
It should be noted from Figure 3c that:
• Over one-quarter of clients showed a successful
• Forty per cent were at least much improved with a reduction in alcohol-related problems of two-thirds or more
• Fifty-eight per cent were at least somewhat improved
with a reduction in alcohol-related problems of one- third or more.
Both UKATT treatments produced statistically significant improvements in alcohol consumption, alcohol
dependence, alcohol-related problems and aspects of general functioning. It is extremely unlikely that such changes would have occurred as a result of natural recovery processes. UKATT has therefore confirmed the effectiveness of MET and found that a novel treatment, SBNT, is no less effective than MET (UKATT Research Team, 2005a).
A detailed summary of UKATT findings on cost-
effectiveness will be given in chapter 14. Suffice it to say here that, as might be expected in view of their
differences in intensity, MET was shown to be significantly cheaper to deliver than SBNT. However, in a full societal economic evaluation, based on estimates of resources used by clients before and after treatment in the healthcare, social services and criminal justice sectors, there were no statistically significant differences between the two treatments in cost-effectiveness. The second hypothesis (section 3.6.1) was therefore not confirmed.